Hello, and welcome to the presentation, Understanding and Reinforcing Guideline-Driven AF Care. I am Stefan Onrosser, an electrophysiologist from the Goethe University in Frankfurt, Germany. We're going to discuss a few items from the last 2020 European Society of Cardiology Guidelines for the Management of Atrial Fibrillation. And perhaps one of the most interesting and important changes in the guidelines was the introduction of this ABC holistic pathway for patient management. It has, as you can see, three components. A stands for anticoagulation for stroke prevention. B stands for better symptom management, rhythm control, or rate control. And the C stands for cardiovascular and comorbidity optimization. We will today discuss the last two points, the better symptom management, that is predominantly rhythm control, and we're going to start with cardiovascular and comorbidity optimization. We are not going to discuss anticoagulation for stroke prevention. This is done elsewhere. Well, the guideline writers have provided an extensive list of AF risk factors, as you can see here. And this is both, you know, separate clinical entities and factors like smoking or obesity, which is not specific, but nevertheless a very important risk factor for the development of atrial fibrillation. In fact, if you look at the various risk factors, you can see from this study by Lau et al. that the risk factors are actually editing in terms of risk. You can see the hazard ratio for developing atrial fibrillation. This particular study went up from 1.0 to 4.4 for one of five components of risk factors. So this is clearly an additive effect and should be taken into consideration when we are talking about avoiding the development of atrial fibrillation. The guideline writers have provided important statements on this, as you can see at the very top here, there's a class one recommendation to identify and manage risk factors and concomitant diseases as an integral part of treatment in atrial fibrillation patients. In fact, the modification of an unhealthy lifestyle and psychotherapy of intercurrent conditions is recommended to reduce AF burden and symptom severity. Also this is a class one recommendation. And that it works may be obvious from this busy slide here. This is a list of studies which provide the association between risk scores and AF incidents. And to make a long story short, the endpoint measurement is always incident atrial fibrillation. And you can see here from the right column here about outcomes that if you optimize risk profile in these individuals, you reduce the likelihood of incident atrial fibrillation quite significantly by 27 or 32% or what have you. So this is very important. And I really like to get this across that the first step in treatment of patients with atrial fibrillation is to avoid risk factors and to correct risk factors whenever this is possible. The second item I'm briefly discussing with you is rhythm control strategy. There is a class one recommendation again in the guidelines saying that rhythm control therapy is recommended for symptom and quality of life improvement in symptomatic patients with atrial fibrillation. Now if you go to the right hand side of this slide where we present the pathways for patients with symptoms present and symptoms absent, you can see that this is quite different. I'm not going to belabor this in very much detail, but I simply want to point out that even if symptoms are absent, the guideline writers recommend to restore sinus rhythm by cardioversion to really evaluate whether symptoms are present or absent. And assess factors favoring rhythm control amongst them, the fact that a patient presents with the first AF episode or a short history of atrial fibrillation represents one of the most important factors which should guide you to provide rhythm control in this particular patient. And I'm pretty sure that this recommendation in the next edition of the guidelines will be modified according to new trial evidence. And this trial is featuring here very prominently. You can see here the main outcome of the EAST AFNet4 trial presented by Dr. Kirchhoff. And you can see that patients randomized to usual care, this is the red line, had more severe hand points, and those are defined on the left hand side of this slide, than patients randomized to early rhythm control. So not only rhythm control will provide symptom control, but in the future, early rhythm control hopefully will reduce what was seen in EAST AFNet4, namely that the composite of death, cardiovascular causes, stroke, or hospitalization for worsening heart failure is going to be reduced like in this pivotal trial. Another feature of long-term rhythm control is shown here. And that's a very valid concept in my opinion, because it's according to the type and to the amount of structural heart disease. This is patients with no structural heart disease. This is coronary disease and have PEF, for instance, significant valvular disease. And this is for patients with heart failure and reduced ejection fraction. And you can see, and you are probably familiar with this, the various components. This is in alphabetical order, dronadrone, flaconib, propafenone, and sotalola are recommended in this particular patient population. These compounds are recommended in patients with coronary disease or have PEF. And really, if it comes down to systolic heart failure, then only amiodarone is left over. And we can see that treating patients according to this scheme really has some benefit to it. This is a post-hoc analysis of the FENA trial. You recall, this is a trial of dronadrone versus placebo in patients with atrial fibrillation. And you can see that treatment with dronadrone in red here reduces the estimated AF burden quite significantly compared to patients who were randomized to receive placebo therapy. And in the same study, we could demonstrate that the progression to permanent atrial fibrillation is less often encountered in patients treated with dronadrone over two years than compared to patients receiving placebo again. So antiarrhythmic drugs are important and will be important in the future to reduce AF burden and to halt progression to permanent atrial fibrillation. And finally, we have this slide from the guidelines, which details indications for catheter ablation of symptomatic atrial fibrillation. And this is paroxysmal atrial fibrillation. Those are the other phenotypes of atrial fibrillation. I want to draw your attention to this paroxysmal or persistent atrial fibrillation and heart failure with reduced ejection fraction. The guideline writers made this the only occasion where catheter ablation is a class one indication right away without treating antiarrhythmic drug, trying antiarrhythmic drugs before this procedure. You can see that even for patients with paroxysmal atrial fibrillation, this is only a 2A indication and only after failed drug therapy, this progresses, so to speak, to a class one indication. However, if you look at this array of recent studies, all of them comparing antiarrhythmic drug treatment with atrial fibrillation catheter ablation in patients without previous attempts to treat them with drugs, you can see that also this last recommendation is probably going to change for patients with antiarrhythmic drug, naive patients going right away to catheter ablation. As you can see, the outcomes from these three trials where the ablation therapy was always superior to drug therapy. So in summary, ESC guidelines on the management of atrial fibrillation recommend an integrated pathway for patient management. I believe that this is a very important issue. They emphasize the importance of cardiovascular and comorbidity optimization as we have discussed this. The guidelines provide assistance for the use of antiarrhythmic drugs and ablation and future emphasis on early rhythm control according to recent trial results are very likely to be given the many trials which have been published since these guidelines have been written in 2020. Thank you very much for your attention.

European Society of Cardiology

Atrial Fibrillation

ABC holistic pathway

Anticoagulation

Rhythm control therapy